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Medicaid Expansion Case Could Bring Seismic Change To Missouri’s Politics And Economy

 Members of the Missouri Supreme Court stand before hearing a case on July 13, 2021, over the fate of a Medicaid expansion amendment.
Members of the Missouri Supreme Court stand before hearing a case on July 13, 2021, over the fate of a Medicaid expansion amendment.

There was a championship boxing match aura in the Missouri Supreme Court chambers on Tuesday.

And it wasn’t because the proceedings featured two highly skilled attorneys duking it out rhetorically in front of a capacity crowd. The stakes in the case over a 2020 Medicaid expansion ballot item are huge.

If attorneys for three women seeking access to Medicaid are successful, they’ll likely end a nearly decade-and-a-half push to expand the health care program for the poor.

If Attorney General Eric Schmitt’s office manages to keep the amendment inactive, it likely will keep Medicaid restricted to children, disabled people and individuals with little income for the foreseeable future. That’s because it’s highly unlikely the GOP-controlled legislature will bolster the program on its own.

Watching with great interest are people like Alice Nelms. She could be one of roughly 275,000 people who become eligible for Medicaid if the court case goes in expansion advocates’ direction.

“While looking for a new job in the middle of the pandemic, I also face the uncertainty of Medicaid coverage,” Nelms said in a statement from the pro-expansion group Healthcare for Missouri. “Without coverage, my health conditions will worsen and I already know that I will either go without, rack up medical debt, or both."

The GOP-controlled legislature triggered the case when it refused to help pay for expanding the program to those making up to 138% of the federal poverty level. That’s about $17,800 a year for an individual.

Chuck Hatfield, an attorney for the plaintiffs trying to obtain Medicaid services, contends that the legislature did not make specific distinctions about who is eligible for coverage — which means the state has to let people in the expansion population sign up for the program.

He also said that the court tends to shy away from overturning initiatives that the people passed.

“Every provision of the Missouri Constitution has been approved by the vote of the people at some point in the history of this state,” Hatfield said. “Those people elect representatives who help set priorities. But the people also reserve the right to amend their constitution and their laws through the initiative petition process. And because of that, this court has consistently held that every doubt and every ambiguity should be resolved in favor of upholding the will of the people.”

The state’s solicitor general, John Sauer, countered that the legislature was clear that it did not want to fund coverage for the expansion population. And without action by legislators, Sauer said that Medicaid expansion can’t happen.

“Their intent was not to fund the expansion population, but only to fund the pre-expansion population — just as they did in 2019 and 2018 and 2020 and so forth,” Sauer said.

Judges on the Supreme Court could take several routes with their decision, including:

  • Siding with the three women. Once individuals in the expansion population then begin to sign up for Medicaid, the program could run out of money — forcing the legislature to provide a supplemental appropriation to pay health care providers.
  • Siding with the state and saying that the legislature needs to specifically appropriate money for the expansion amendment to be effective.
  • Sustaining Cole County Judge Jon Beetem’s decision in which he completely struck down the Medicaid expansion amendment because it ran afoul of a provision barring initiative petitions that appropriate money without a funding source.

In some respects, the second and third options would produce the same result. The GOP-lead General Assembly is highly unlikely to expand Medicaid, so conditioning expansion on legislative consent would effectively invalidate the 2020 amendment.

It’s unclear when the court will render its decision, but given that the case has moved through the process fairly quickly, it will likely be in the coming weeks.

In addition to drawing an overflow crowd on Tuesday, the case has prompted a slew of supporting briefs on both sides. That includes one from House Republicans who argue against expansion.

“If the legislature retained the authority to decide whether to fund or not to fund Medicaid expansion, then the decision of the legislature not to fund Medicaid expansion must be affirmed,” the brief states. “If Amendment 2 took away the legislature's authority to decide whether to fund or not to fund Medicaid expansion and left it without discretion, then Amendment 2 violates the constitutional prohibition against appropriating by initiative without creating the necessary revenues. If Amendment 2 violated the constitution, then the decision of the legislature in the 2021 session not to fund Medicaid expansion must be affirmed since the legislature cannot be bound by an unconstitutional amendment.”

Health care companies and regional business groups submitted briefs in favor of expansion.

The brief from business groups includes support from the Missouri Chamber of Commerce, which has historically backed GOP lawmakers and issues. Jason Hall of Greater St. Louis Inc., another supporter of expansion, said the issue has huge implications for hospitals and major health care companies.

“So we can’t hold back those benefits now, particularly in the situation we found ourselves in with COVID,” Hall said. “It is important to make sure that health care is accessible and we bring home the economic benefits of expansion to the economy of this state.”

The Supreme Court decision will affect thousands of people with serious health conditions for which treatment would be financially out of reach without access to Medicaid. Currently, a single mother with one child has to make less than $3,000 a year to qualify for Medicaid.

“We’re counting on this Medicaid expansion to go through to meet the needs that they have,” said Joel Ferber of Legal Services of Eastern Missouri.

There are also major financial implications to how the court decides. If Medicaid expansion goes forward, Missouri would have access to more than $1 billion from the latest federal coronavirus relief fund — money that could conceivably pay for the state cost of the program for years.

Republicans like House Majority Leader Dean Plocher, though, don’t see that as a reason to pursue expansion.

“You’re then promising to spend the money in perpetuity when you’ve only got a finite amount of money coming in. And then we’re saying, ‘We’ve got to figure out where that money comes from,’” said Plocher, R-Des Peres.

Others say the program will be cost effective and could save the state money.

For people like Nina Canaleo of Kansas City, the court battle is about more than who wins or loses in court — or budgetary policy.

Canaleo works as a maintenance worker and would qualify for Medicaid under expansion. She has multiple sclerosis, and Medicaid could help pay for critical medication that would make her life better.

“I’m not ready to not be walking,” Canaleo said. “I have to work. And I have to walk to take care of my kid and to live. And it’s really upsetting. I was really super excited. ‘Oh, I’m going to vote on this. Yay! Good things do happen for people.’ And to have them just dangle it in front of our face and say, ‘Oops, just kidding.’ It’s really frustrating.”

Follow Jason on Twitter: @jrosenbaum

Copyright 2021 St. Louis Public Radio

Since entering the world of professional journalism in 2006, Jason Rosenbaum dove head first into the world of politics, policy and even rock and roll music. A graduate of the University of Missouri School of Journalism, Rosenbaum spent more than four years in the Missouri State Capitol writing for the Columbia Daily Tribune, Missouri Lawyers Media and the St. Louis Beacon. Since moving to St. Louis in 2010, Rosenbaum's work appeared in Missouri Lawyers Media, the St. Louis Business Journal and the Riverfront Times' music section. He also served on staff at the St. Louis Beacon as a politics reporter. Rosenbaum lives in Richmond Heights with with his wife Lauren and their two sons.